BALLICO-CRESSEY ELEMENTARY SCHOOL DISTRICT ATHLETIC PARTICIPATION FORM PERSONAL INFORMATION

STUDENT NAME: ________________________________________________________________________________________ ADDRESS: DATE OF BIRTH:

(Last) (First) (Middle) ________________________________________________________________________________________________ (Street) (City) (Zip Code) ___________________ AGE: ____________ GRADE: ____________ PHONE: _______________________________ INSURANCE STATEMENT

UNDER STATE LAW, SCHOOL DISTRICTS ARE REQUIRED TO ENSURE THAT ALL MEMBERS OF SCHOOL ATHLETIC TEAMS HAVE ACCIDENTAL INJURY INSURANCE THAT COVERS MEDICAL AND HOSPITAL EXPENSES. THIS INSURANCE REQUIREMENT CAN BE MET BY THE SCHOOL DISTRICT OFFERING INSURANCE OR OTHER HEALTH BENEFITS THAT COVER MEDICAL AND HOSPITAL EXPENSES. SOME PUPILS MAY QUALIFY TO ENROLL IN NO-COST OR LOW-COST LOCAL, STATE, OR FEDERALLY SPONSORED HEALTH INSURANCE PROGRAMS. INFORMATION ABOUT THESE PROGRAMS MAY BE OBTAINED BY CALLING 1 (800) 880-5305 (FOR INFORMATION ON HEALTHY FAMILIES AND MEDI-CAL PROGRAMS).

The Ballico-Cressey makes available, on request, insurance through a private insurance company for all students which will meet the Education Code insurance requirements including $1500 of scheduled medical and hospital benefits (Education Code section 32220-32224). Students must have insurance before they are allowed to practice and participate in the athletic program. Identify coverage below: 1. 2. 3.

I have Medi-Cal coverage  Yes  No I have private medical insurance coverage:  Yes  No Name of Company: __________________________________ I am purchasing the private insurance that is being made available by the District:  Yes  No

DISCLOSURE OF KNOWN MEDICAL CONDITIONS Please list ALL known medical conditions that may affect or be affected by physical activity. (ex. Asthma, allergic reactions, heart conditions, diabetes, etc.). Next to each condition, please list the recommended treatment. MEDICAL CONDITION TREATMENT _________________________ ________________________________ _________________________ ________________________________ _________________________ ________________________________ PARENTAL PERMISSION AND HOLD HARMLESS WARNING: PARTICIPATION IN ATHLETICS MAY RESULT IN SEVERE INJURY, INCLUDING PARALYSIS AND DEATH. CHANGES IN RULES, IMPROVED CONDITIONING PROGRAMS, BETTER MEDICAL COVERAGE AND IMPROVEMENTS IN EQUIPMENT HAVE REDUCED THESE RISKS BUT IT IS IMPOSSIBLE TO TOTALLY ELIMINATE SUCH OCCURRENCES IN ATHLETICS. Players can reduce the chance of injury by

obeying all safety rules in their sport, reporting all physical problems to their coach, following a proper conditioning program and inspecting their equipment daily. EVEN IF ALL OF THESE REQUIREMENTS ARE MET, AND EVEN IF THE ATHLETE IS USING EXCELLENT PROTECTIVE EQUIPMENT, A SERIOUS ACCIDENT MAY STILL OCCUR. AS A CONDITION OF PARTICIPATION IN ATHLETICS WE ACKNOWLEDGE THAT WE HAVE READ AND UNDERSTAND THIS WARNING STATEMENT AND THAT WE HEREBY ASSUME ALL OF THE ABOVE RISKS AND, EXCEPT IN THE CASE OF GROSS NEGLIGENCE, WILL HOLD THE DISTRICT, ITS OFFICERS, AGENTS, AND EMPLOYEES, HARMLESS FROM ANY AND ALL LIABILITY, ACTIONS, DEBTS, CLAIMS, AND DEMANDS OF EVERY KIND AND NATURE WHATSOEVER WHICH MAY ARISE OUT OF OR IN CONNECTION WITH THE STUENT’S PARTICIPATION IN ATHLETICS.

I hereby guarantee to keep medical insurance coverage in force which meets or exceeds legal requirements for the entire duration that my son/daughter participates in athletics, including but not limited to the payment of premiums, deductibles and co-pays. I understand that we (I) are (am) solely financially responsible for any cost and/or all indebtedness incurred as a result of any emergency and/or routine medical and/or surgical treatment and services prescribed by the attending physician for my child/ward, including all charges not covered by insurance. PARENTAL RESPONSIBILITIES In order for our athletic teams to be successful, they will require the continued support and participation for all players. Student athletes that have committed to being on a team are required to attend all scheduled practices and events. In the case of an emergency, athletes will need to notify their coach or athletic director as soon as possible. Athletes that do not participate in practice and who do not have an excused absence, will not be allowed to participate in the opening round of the following game. Parents please make sure that athletes are available for all practices and games. Please make sure that students have appropriate transportation to and from each practice and game. Estimated leave times, end times, and return times will be clearly stated on all schedules. Athletes that are not picked up on time will be given a warning. If there continues to be an issue with transportation, either making it to practice and games as well as picking up from practices and games, the athlete may be asked to leave the team. Athletes that wish to leave from an away game with their parents, guardians, or adult siblings may do so at any time as long as they have notified the coach prior to leaving the event. Students may not ride home with another athlete’s family unless prior consent has been given by the district superintendent before the leave time of the game.

STUDENT-ATHLETE RESPONSIBILTIES In order to participate in the athletics program at Ballico-Cressey, students are expected to maintain a specific grade point average, adhere to a sportsmanship code of conduct, and participate fully. Students wishing to participate in athletics must maintain a trimester GPA of 2.0 or higher. This will be determined by trimester report cards and will not be influenced by progress reports. Students may not participate if they have more than one F in any subject, even if they have a 2.0 GPA. Student-athletes area also required to stay current on all classroom and homework assignments. Missing class for a game or tournament does not excuse any student from completing required assignments or extend the due date on any assignment. One of the most important factors in becoming a great athlete is being able to maintain a sportsmanlike attitude. Student athletes will be courteous and respectful of all coaches, teammates, and opponents at all times. Athletes that show inappropriate or disrespectful attitudes on the field or on the sidelines will immediately be removed from the game and will meet with the Athletic Director the following school day. If the negative behavior continues, it may result in permanent dismissal from the team. Students that have committed themselves to being a part of an athletic team, will be responsible for participating fully in all practices and events. Practices are required and are essential to the success of the team. If you must miss a practice or game due to an emergency, please notify your coach or Athletic Director as soon as possible. Students that do not have an excused absence from practice will not be allowed to participate in the opening round of the next game. Students that have continued absences from practices or games may be asked to leave the team. Attending another city or traveling sporting event does not qualify as an acceptable excuse for your absence. The schedules will be made available to you prior to the start of the season. If there are conflicts with other teams you will need to make a choice! ACKNOWLEDGEMENT AND CONSENT *I hereby give my consent for my son/daughter to compete in all athletics during the current school year and the following summer, if applicable. *I hereby give my consent for my son/daughter to travel with a representative of the school district on interscholastic athletic trips. *I have read and reviewed all stated rules and responsibilities. IN THE EVENT THIS STUDENT IS INJURED, THE SCHOOL DISTRICT OFFICIAL IS HEREBY GRANTED MY PERMISSION TO ADMINISTER FIRST AID AND TO SECURE MEDICAL AND/OR SURGICAL TREAMENT. WE HAVE READ, UNDERSTAND, AND AGREE TO ALL TERMS AND CONDITIONS OF BOTH SIDES OF THIS DOCUMENT. PARENT or LEGAL GUARDIAN PRINT: ________________________________________________

DATE: ______________________

PARENT or LEGAL GUARDIAN SIGN: _________________________________________________ PARENT EMAIL: __________________________________________________________

PRIMARY PHONE: ______________________

STUDENT: _________________________________________________________________________

DATE: ______________________

SPORT (circle):

VOLLEYBALL

BOYS SOCCER

GIRLS SOCCER

BOY’S BASKETBALL

TRACK

BASEBALL

SOFTBALL

GIRL’S BASKETBALL

PLEASE NOTE Athletes are not guaranteed a certain amount of play time. The coach will determine who and how. There are not a certain number of minutes each athlete is allotted to play in each game; therefore, there is not a guarantee every athlete will play in every game. The time each athlete is allotted to play is determined by a number of factors that include, but not limited to: practice attendance, knowledge of the game, level of understanding to play efficiently, and number of eligible athletes available to the team.

FOR ANY QUESTIONS OR CONCERNS REGARDING THE RULES SET FORTH IN THIS AGREEMENT PLEASE CONTACT MR. MARTINEZ (209) 632-5371 ext. 7213 OR [email protected]